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SCREENING OR BIOPSY PROCEDURES Combined Items Length: 4 First Digit: Item Name: Biopsy Procedure Item Length: (1) Second Digit

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SCREENING OR BIOPSY PROCEDURES Combined Items Length: 4 First Digit: Item Name: Biopsy Procedure Item Length: (1) Second Digit Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES Combined Items Length: 4 First digit: Item Name: Biopsy procedure Item Length: (1) Second digit: Item Name: Guidance Item Length: (1) Third digit: Breast: Palpability of primary Prostate: Approach for biopsy of primary (1) Item Length: (1) Fourth digit: Breast: First detected by Prostate: Biopsy of other than primary Item Length: (1) Data Type: Numeric Allowable Values: Site Specific Required Data Set “Screening or Biopsy Procedures” are biopsies that do not grossly remove the primary tumor and/or surgical margins were macroscopically involved. Screening and biopsy procedures are collected on two sites, breast and prostate. If the primary tumor was grossly removed during the biopsy procedure, code all of the screening and biopsy items 0 (not done, not a separate procedure). The biopsy would be coded as cancer-directed surgery. If the primary site is other than breast or prostate, code all data items 0. BREAST Biopsy Procedure (Breast Only) 0 Not done, not a separate procedure 1 Biopsy, NOS 2 Fine needle aspiration (cytology) 3 Core biopsy (histology) 5 Excision of major duct (if procedure removes all gross primary tumor, code as cancer-directed surgery) 9 Unknown if biopsy performed; death certificate only 178 / Registry Operations and Data Standards Revised 8/00 CODE DEFINITION (BIOPSY PROCEDURE) 0 No screening or biopsy procedures were done. Biopsy was performed, but was a part of first course surgery (e.g, excisional biopsy). Not a breast or prostate primary 1 A biopsy was done, but the type is unknown. 2 A fine needle aspiration was done and the results were interpreted by cytology. 3 A core needle biopsy was done and the results were interpreted by histology (tissue). 5 A major duct was excised, but this excision did not remove all gross primary tumor. 9 It is unknown if the patient had a biopsy; death certificate only cases. Revised 8/00 Registry Operations and Data Standards / 178A Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES (Continued) Guidance (Breast Only) 0 Not guided; no biopsy of primary site 1 Guided, NOS 2 Radiographic NOS (no dye or dye unknown) 3 Mammographic; wire/needle localization 4 Stereotactic 5 Dye only 6 Dye plus (1-3) 7 Ultrasound 9 Unknown if guided; biopsy performed; death certificate only CODE DEFINITION (GUIDANCE) 0 No biopsy of primary site was done, or the biopsy was part of first course surgery (e.g., excisional biopsy). A biopsy of the primary site was done, none of the guidance techniques listed in codes 1-7 were used. Not a breast or prostate primary. 1 A biopsy was done, it is known that guidance was used, but the type of guidance is not documented/known. 2 A biopsy was done guided by any radiographic technology. No dye was used to localize the tumor or it is unknown if dye was used to localize the tumor. 3 The tumor was localized by needles or wire placed with mammograpic guidance. 4 Stereotactic biopsy was performed, using a fine needle (cytology), or a core needle (histology). 5 Tumor was localized using dye only. 6 Tumor was localized using dye and guided by one of the techniques described in codes 1-3. 7 Biopsy was guided by ultrasound. 9 It is unknown if a biopsy was done. A biopsy was done, it is unknown if a guidance technique was used. Death certificate only case. 178B / Registry Operations and Data Standards Revised 8/00 Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES (Continued) Palpability of Primary (Breast Only) 0 Not palpable 1 Palpable 9 Palpability not stated; death certificate only First Detected By (Breast Only) Record the method by which the breast mass or abnormality was first recognized. 0 Not a breast or prostate primary 1 Patient first felt lump or noted nipple discharge 2 Physician first felt lump 3 Mammography -routine (screening) 4 Occult; incidental finding during other procedure 9 Unknown how first detected Revised 8/00 Registry Operations and Data Standards / 178C Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES (Continued) PROSTATE Biopsy Procedure (Prostate Only) 0 Not done, not a separate procedure 1 Incisional biopsy, NOS 2 Fine needle aspiration (cytology) 3 Needle core biopsy; biopsy gun (histology) 4 Sextant biopsy 9 Unknown if biopsy of primary was done; death certificate only CODE DEFINITION (BIOPSY PROCEDURE) 0 No screening or biopsy procedures were done. Screening or biopsy procedures were done, but were coded as first course surgery (e.g., TURP). Not a breast or prostate primary. 1 A biopsy was done, but the tumor was not grossly removed during this procedure and/or surgical margins were macroscopically involved, or it is unknown whether it was incisional or a core needle biopsy. 2 A fine needle aspiration was done and the results were interpreted by cytology. 3 A core needle biopsy was done and the results were interpreted by histology (tissue). A biopsy gun was used to get a tissue sample that was interpreted by histology. 4 A biopsy was done using a sextant. 9 It is unknown if the patient had a biopsy; death certificate only cases. 178D / Registry Operations and Data Standards Revised 8/00 Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES (Continued) Guidance (Prostate Only) 0 Not guided; no biopsy of primary 1 Guided, NOS 2 Radiographic 3 Ultrasound 9 Unknown if guided, biopsy performed; death certificate only CODE DEFINITION (GUIDANCE) 0 No biopsy of primary site was done, or the biopsy was part of first course surgery (e.g., TURP). A biopsy of the primary site was done, none of the guidance techniques listed in codes 1–7 were used. Not a breast or prostate primary. 1 A biopsy was done, it is known that guidance was used, but the type of guidance was not documented/known. 2 A biopsy was guided by any radiographic technology. No dye was used to localize the tumor or it is unknown if dye was used to localize the tumor. 3 Biopsy was guided by ultrasound. 9 It is unknown if a biopsy was done. A biopsy was done, it is unknown if a guidance technique was used. Death certificate only case. Revised 8/00 Registry Operations and Data Standards / 178E Stage of Disease at Diagnosis SCREENING OR BIOPSY PROCEDURES (Continued) Approach for Biopsy of Primary (Prostate Only) 0 No biopsy 1 Transrectal 2 Transperineal 3 Transurethral 4 Laparoscopic 5 Open (laparotomy) 9 Unknown approach, but biopsy performed; death certificate only Biopsy of Other Than Primary (Prostate Only) 0 No biopsy of other than primary 1 Biopsy of seminal vesicle(s), NOS 2 Unilateral 3 Bilateral 4 Other than seminal vesicle 5 4 + 1 6 4 + 2 7 4 + 3 9 Unknown if biopsy of other than primary; death certificate only 178F / Registry Operations and Data Standards Revised 8/00 First Course of Treatment DATE OF FIRST COURSE TREATMENT (Date Started) Item Length: 8 Includes Surgery of Primary Site, Scope of Regional Lymph Node Data Type: Numeric Surgery, and Surgery of Other Regional Site(s), Distant Site(s) Required Data Set or Distant Lymph Node(s) Date of first course treatment is the month, day, and year (MMDDCCYY) of the first course therapy. The first two digits are the month, the third and fourth digits are the day, and the last four digits are the year. Month Day Year 01 January 01 Use four-digit year 02 February 02 9999 year unknown 03 March 03 04 April .. 05 May .. 06 June 30 07 July 31 08 August 99 Day unknown 09 September 10 October 11 November 12 December Examples: Record June as 06 Record December 15, 1996 as 12151996 If the physician decides not to treat the patient, record the date of this decision as the date of initial treatment. The physician may decide not to treat the patient because of co-morbid conditions, advanced disease, or because the accepted management of the cancer is to observe until the disease progresses or until the patient becomes symptomatic. Example: On February 12, 1996 the physician says that a low-stage prostate cancer patient will be observed until the Prostatic Specific Antigen (PSA) starts to rise. Enter 02121996 as the date of first course treatment. If the patient refuses treatment, record the date of this decision as the date of initial treatment. Record the date of death for autopsy only cases. If the patient is diagnosed at the reporting facility and no further information is available (patient is lost to follow-up) record the date the patient was last seen at the reporting institution. Code 99999999 when it is unknown if any treatment was given, or the date is not known, or the case was identified by death certificate only. If the exact date of the beginning of treatment is not available, recording an approximate date is preferred. Revised 8/00 Registry Operations and Data Standards / 179 First Course of Treatment DATE OF DIAGNOSTIC, STAGING, OR Item Length: 8 PALLIATIVE PROCEDURES Data Type: Numeric Required Data Set Collecting dates for each treatment modality allows sequencing of multiple treatments and aids evaluation of time intervals (from diagnosis to treatment and treatment to recurrence). Date of Diagnostic, Staging, or Palliative Procedures is the month, day, and year (MMDDCCYY) that diagnostic, staging, or palliative procedures were performed at any facility. The first two digits are the month, the third and fourth digits are the day and the last four digits are the year. Month Day Year 01 January 01 Use four-digit year 02 February 02 9999 year unknown 03 March 03 04 April .. 05 May .. 06 June 30 07 July 31 08 August 99 Day unknown 09 September 10 October 11 November 12 December 99 Month unknown Examples: Record June as 06.
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